Treatment of diabetes mellitus in hospitals Done by: Fatimah Al-Shehri Pharm.D Candidate King Abdulaziz university Supervised by: Dr.Hani Hassan Clinical pharmacist/internal medicine.

Outline -Introduction. -Goals in the hospital settings. -Prevention of hyperglycemia and hypoglycemia. -Treatment.

Introduction: Glycemic control is unstable in hospitalized patients because of : - Stress of the illness or procedure. - Concomitant changes in dietary intake - Physical activity. -Frequent interruption of the patient's usual antihyperglycemic regimen.

Goals in hospitals : - Avoid hypoglycemia. -Avoid severe hyperglycemia. -Avoid volume depletion --Avoid electrolyte abnormalities. -Ensure adequate nutrition.

Avoidance of hypoglycemia: Hypoglycemia (ie, serum glucose conc <70 mg/dL [3.9 mmol/L]) Hospitalized patients are particularly vulnerable to severe, prolonged hypoglycemia ???. Consequences of hypoglycemia: - It effects the counter-regulatory hormones, especially catecholamines, which may possibly induce arrhythmias and other cardiac events. - If the blood glucose falls to 50 mg/dL (2.8 mmol/L), transient cognitive deficits..

Avoidance of hyperglycemia: It is a long-standing clinical observation when blood glucose sugar is above 110mg/dl. Hyperglycemia consequences : - Volume and electrolyte disturbances mediated by osmotic diuresis. - caloric and protein loss in under-insulinized patients. -Immune and neutrophil function is impaired.

Glycemic targets in hospitals: Target of the blood sugar deepens on the severity of the illness. A-Critically ill patients. B-Non-critically ill patients.

:Non-critically ill Glycemic goals in non-critically ill patients : <140 mg/dL (7.8 mmol/L) for general hospitalized patients, with all random glucose <180 mg/dL (10.0 mmol/L) To avoid hypoglycemia : FBG concentrations : 90 to 100 mg/dL (5.0 to 5.6 mmol/L). In general, all glucose levels should be kept below 180 mg/dL (10.0 mmol/L) to avoid dehydration, caloric loss, glycosuria, and to reduce the risk of infection and, although rare, ketoacidosis.

Treatment

Treatment of hyperglycemia in hospital: 1- The type of diabetes. 2-The patient's current BG concentrations. 3-Prior treatment. 4-The severity of illness. 5- The expected caloric intake during the acute episode..

Treatment options : - Insulin. - Oral hypoglycemic.

1-Insulin : Types of insulin: 1-long-acting insulin: such as glargine or detemir. 2-Intermediate-acting insulin:such as NPH. 3- Premeal rapid or short-acting insulin such as :regular insulin, aspart, lispro.

Insulin analogs:

Insulin regimen used in hospitalized patients : 1-Fixed dose regimen: -Basal –bolus insulin regmin (BBI). -Regular regimen). 2-Sliding scale insulin regimen.( SSI) 3-Insulin correction. 3-Insulin infusion.

1-Basal bolus insulin regimen : 1-Basal –bolus regimen: Basal Insulin: Prevents between meal and overnight hyperglycemia Bolus insulin: Limits hyperglycemia after meals.

1-Basal bolus insulin regimen: Proactive Approach: Anticipate major change in blood glucose levels and prevent them from occurring Insulin therapies that mimic physiological release of insulin. Individualized basal-bolus insulin therapies (BBI)

:2-Sliding-scale insulin SSI: involves use of regular insulin or a rapid-acting insulin analogue provided without any other scheduled short-acting or long-acting insulin.

2-Sliding scale insulin: Urine glucose monitoring. Boil urine sample with solution containing copper sulfate Sliding Scale by Elliot Joslin.

3-Today’s Insulin Sliding Scale: Blood glucose monitoring, Use of glucometer. Regimens for rapid-acting or short-acting insulin. Schedule:TID-QID. Units :Blood glucose level : 0 Unit.<6mmol/L 2 Units mmol/L 4 Units mmol/L 6 Units mmol/L 8 Units mmol /L 10 Units mmol/L 12 Units mmol/L 14 Units mmol/L Call MD. >20

Which sliding scale :

Advantages & Disadvantages of ISS: AdvantagesDisadvantages Not individualized Creates a “roller coaster” effect “Reactive Approach” Not evidence based practice Can initiate right away SimpleConvenient Umpierrez GE, Palacio A, Smiley D. Sliding scale insulin use: myth or insanity? Am J Med 2007; 120: 563– 567

2-Insulin sliding scale :

SSI - Traditional Insulin Sliding Scales: No basal insulin. - Supplemental Scale or Correction Scale: ISS + (basal insulin +/- bolus insulin) Primarily used AS: dose-finding strategy (bolus insulin dosage) -As a supplement when rapid changes in insulin requirements (i.e. stress or illness)

ISS vs. BBI?

Evidence against SSI:

Rabbit trial 2:

Evidence against the SSI :

Although sliding scale insulin regimens are prescribed for the majority of inpatients with diabetes, they appear to provide no Benefit.. in fact, when used without a standing dose of intermediate- acting insulin, they are associated with an increased rate of hyperglycemic episodes.

Evidence against SSI: MJA 2012; 196: 266–269 doi: /mja

Mean change in BGL from baseline in the two insulin therapy groups. MJA 2012; 196: 266–269 doi: /mja

Conclusion : under routine clinical conditions, implementation of a BBI protocol to manage hyperglycaemia in hospitalised patients resulted in a lower mean daily BGL than did SSI. BBI is associated with an increase in mild, but not severe, hypoglycaemia. We recommend that protocols for inpatient glycaemic control based around BBI be widely implemented.

Time to stop SSI: 1-Unaware of problems associated with ISS 2- Unwilling to make changes to therapies initiated by another physician 3- Lack of evidence Long-term care (LTC) setting

QUESTION: AS clinical pharmacist, When making your recommendation to the physician, what information might you want to include about SSI and BBI ? A-Basal-bolus is a proactive approach to management, preventing hyperglycemia without increasing the risk of hypoglycemia. B-The use of insulin sliding scale is not evidence-based practice. C-Insulin sliding scale is most likely the medication causing the patient to fall and affecting patient’s ability to focus. D- All of the above.

:3- Correction insulin The dose of correction insulin should be individualized based upon relevant patient characteristics such as : - Previous level of glucose control. - Previous insulin requirements. - The carbohydrate content of meals. Correctional insulin needs : rule: 1800/TDI=number of mg/dl of glucose lowering per 1 unit of rapid acting insulin. ((1 unit of rapid actin insukin will reduce the BG concentration by x mg/dl rule :1500/TDI.

:3- Correction insulin Correction insulin alone may also be used : - As initial insulin therapy in patients with type 2 diabetes previously treated at home with diet or an oral agent, who will not be eating regularly during hospitalization. It is typically administered every six hours as regular insulin. However, if the patient is eating and finger stick glucoses are consistently elevated (>180mg/dL [10.0 mmol/L]) : (basal-bolus regimen).

Insulin requirements: 50 % of the total daily dose can be given as BI. The remaining 50% can be given in equally divided doses prior to meals (1/3 prior to each meal). 2-Regular insulin:1-Basal –bolus regimen: 70%(2/3) of the dose given in the morning. 30%(1/3) of the dose given in the evening. 50% basal insulin. 50% bolus insulin. e.g: 25 units/day (NPH) units in the morning. - 9 units in the evening. e.g: 25 units/day. - Glargin:12.5 unit as basal -Lispro: 12.5 ( ) as bolus.

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4-Insulin infusion: Insulin infusions are typically used in critically ill ICU patients, rather than in patients on the general medical wards of the hospital.

Oral hypoglycemic agents:

References : pl_1/s43.full